Transvaginal hydrolaparoscopy (THL) in the evaluation of the infertile woman.

Abstract

Objective: The purpose of this report is to review our experience with THL. Advanced Women’s Health Institute performs THL, instead of hysterosalingography (HSG), as the initial procedure for the evaluation of pelvic anatomy, and in place of laparoscopy (L/S) in selected patients. Operative instrumentation (OPTHL) is now available and we have used this to treat minimal and mild endometriosis, and filmy adhesions. Design: Retrospective review. Materials/Methods: Beginning in February, 1999, all infertility patients (pt) were offered THL, hysteroscopy (H/S), and chromopertubation, instead of HSG, or L/S. All pt had a pelvic exam and ultrasound prior to THL. Pt with indications for L/S (fibroids, ovarian cysts, etc.) were excluded, as were pt with unfavorable pelvic exam or obesity. THL was deemed normal if all available anatomy was identified, the tubes were patent, and no pathology was found. THL was abnormal if endometriosis, tubo-ovarian adhesions, or tubal obstruction was identified. THL was complete when all anatomy could be evaluated, and incomplete when all anatomy could not be evaluated. OPTHL was performed using a 5 fr. bipolar electrode. Initially, IV sedation was used for THL. All in hospital pt had IV sedation. We rapidly realized that only oral analgesics were necessary. All OPTHL was performed with IV sedation. Results: Through January 2001, 53 women have undergone THL. A complete exam was possible in 50 (94%), and incomplete in 3 (6%). One perforation into a retroflexed uterus occurred. There were no other complications. A normal pelvis was found in 26 (49%), endometriosis in 11 (21%), adhesions in 8 (15%), tubal disease in 5 (9%), and 3 (6%) were incomplete. THL was performed in office in 47 (89%), and in hospital in 6 (11%). IV sedation was used in 19 (36%); 34 (64%) had oral analgesics. Visual analog pain scores (0 = no pain, 10 = worst pain) were kept in 27 oral analgesic pt at trocar insertion (4.2 ± 0.7), mid procedure (2.2 ± 0.2), and end procedure (1.2 ± 0.04). A second procedure was necessary in 11 of 47 (23%) office THLs. In 38 pt without prior HSG, THL was normal in 21 (55%), abnormal in 14 (37%), and incomplete in 3 (8%). Normal tube (s) at HSG were reported in 13 pt, THL was normal in 5 (38%) and abnormal in 8 (62%). OPTHL has been performed 8 pt (endometriosis 7, adhesions 1). Of 53 pt undergoing THL, 6 (11%) were recommended IVF, 7 (13%) declined therapy, and 3 (6%) have not cycled. This left 37 pt who cycled. Pregnancy occurred in 22 (59%) pt, an average of 2.4 cycles. Results: Not applicable. Conclusions: Pelvic pathology found at THL is similar to published L/S reports. THL is essentially as easy to perform in office as hysteroscopy. Because of the high incidence of pelvic pathology found in infertile women, we recommend THL, instead of HSG, as the initial evaluation tool.